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    "When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov

    ''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.''
    -Robert Ehrlich, drug advertising executive.

    "Opinions are like sphincters, everyone has one." - Chris Rangel

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    Monday, April 07, 2003

    SARS in China: How’s it going? Who knows? (Or does WHO know?)

    Communist party sources in Beijing said the new leadership under President Hu Jintao and Premier Wen Jiabao had urged central and regional officials to issue words of reassurance to the international community.

    Despite its upbeat stance, however, China's Ministry of Health announced Monday that the death toll from the virus had risen to 53, with 1,268 people infected.

    It was also revealed that people had died of the mysterious illness in more of its provinces than previously reported, according to Reuters.

    But that’s not what‘s happening in the universe inhabited by Chinese officials:

    Most official papers on Monday covered a high-profile visit by Premier Wen to the China Disease Control Center.

    Wen said the disease was "under effective control" in China, and that the great majority of provinces and cities had no SARS cases at all.

    Sounds like he went to the same school of public policy as this guy.

    posted by Sydney on 4/07/2003 08:22:00 AM 0 comments

    Useful Illnesses: We've all heard the phrase "useful idiots," as applied to people who unwittingly provide succor to the enemies of their own ideals (used most recently to describe war protesters and Peter Arnett), but there are also "useful illnesses," as described in a review (requires subscription) in the New England Journal of Medicine of the book Whiplash and Other Useful Illnesses:

    Spine specialists have long known that patients with secondary gains — workers' compensation claims or lawsuits — have significantly worse outcomes than those who do not. In fact, in scientific studies designed to judge the efficacy of interventions, investigators must exclude such patients or report their results separately. Of course, such considerations are not limited to spine-related injuries. In a broad sense, Whiplash and Other Useful Illnesses is about the way in which illnesses for which patients may receive compensation are created and sustained for the benefit of a few at the expense of many.

    Sounds interesting. There’s also this revelation:

    Malleson draws parallels with other illnesses that were "fashionable" in other periods, such as "railway spine" and "repetitive strain injury," which reached nearly epidemic proportions in other countries until laws allowing compensation were rescinded. After the revocation of these laws, the ailments virtually disappeared.

    There have been studies that show that injuries take longer to resolve when there are unresolved compensation issues - such as lawsuits and worker’s compensation. And although this is only anecdotal evidence and nothing to base public policy on, I’ve noticed in my practice that patients recover in a matter of days to weeks when they’re the ones at fault, compared to patients who are the victims of accidents, who take months to get better.

    And the time for recovery does clearly seem to be related to compensation. This is what happens. A person has an accident, and as a result sprains their neck. As in any sprain, the pain is at its worst the first few days, then it gradually gets better. But, even when things are mostly better, there are still, on occasion, twinges of brief pain that come and go. For the person not involved in litigation, these twinges are barely noticed because they’ve moved on. Their injuries are no longer a major focus of their lives. They perceive these twinges as nothing more than the usual aches and pains that everyone suffers now and then.

    But, the person who is trying to get compensation for their injuries, either through the legal system or the worker’s comp system, has the constant fear that things might get worse. Once they settle the case, that’s it. No future claims will be paid by the other party. So, when they feel those twinges, their inclination is to wonder if they might be harbringers of worse things to come, of disabilities that won't be compensated. That anxiety only serves to magnify the pain. Which keeps the case open. Which costs society a lot of money.

    The reviewer also throws out this observation from the book:

    A psychiatrist by training, he particularly faults physicians for publishing poor scientific work in an effort to advertise themselves as experts in the field. This advertising allows them to secure an additional lucrative source of income in the face of a contracting health care market.

    Now that’s a criticism that could be fairly levelled at a great many researchers these days, and not just in the field of “useful illnesses.” It's a trend against which we should remain forever vigilant.
    posted by Sydney on 4/07/2003 07:53:00 AM 0 comments

    The Origin of (Viral) Species: How the SARS virus may have come to be:

    Experts say the new human coronavirus, if it causes SARS, probably arose when it managed to incorporate similar but foreign RNA, which, like DNA, can make up the genome or genetic code of microorganisms. Such alien RNA would make it a kind of natural hybrid.

    Human coronaviruses, said Dr. Mark R. Denison, an expert at Vanderbilt University, are like the mild-mannered next-door neighbor with a proclivity for doing the unexpected. "It's always the quiet ones you worry about," he said.

    ....Coronaviruses, he added, "are ubiquitous and are relatively promiscuous" in their ability to infect different species. Infection of a single host with two different coronaviruses can easily lead to recombination and the emergence of new forms, he said, and "that's probably what happened here."

    Guangdong Province in southern China, where the illness is believed to have emerged late last year, has dense concentrations of domestic waterfowl in close proximity to pigs and people. Experts say those are ideal conditions for transferring diseases among different species and for the emergence of a new strain of flu virtually every year. "It's no surprise that other viruses can take advantage of similar mechanisms," said Dr. Block of Stanford.

    The one constant in life is change, even for viruses.
    posted by Sydney on 4/07/2003 07:09:00 AM 0 comments

    Housekeeping: I tried to update my links last night and somehow ended up altering the template to the point that none of the posts would show up. I stayed up too late fixing it, but in the process I may have lost some of my previous links. If I deleted your link to the left, I apologize. I will fix it, but not this morning. I'm afraid to do anything to the template until I have a block of uninterrupted time to fix any problems that might arise. In the meantime, here are the sites will soon be included in the list on the left:

    Day by Day
    Feet First
    Tales of Hoffman
    The Eyes Have It
    posted by Sydney on 4/07/2003 06:56:00 AM 0 comments

    Sunday, April 06, 2003

    Lagniappe, Farewell: Derek Lowe has moved (gone commercial). His new site is In the Pipeline. I’ll miss the old title, “Lagniappe” - Cajun for small, unexpected gift, but his content will be the same - pharmaceutical industry and research developments.

    posted by Sydney on 4/06/2003 11:26:00 PM 0 comments

    Humor Quiz: Find out what humor troubles you.
    posted by Sydney on 4/06/2003 10:29:00 AM 0 comments

    MedMal in North Carolina: It's taken a back seat recently to SARS and the war, but the medical malpractice insurance problem isn't going away. In North Carolina, doctors are planning a rally to support tort reform. How bad are things there? This bad:

    His firm, Senn Dunn Marsh & Roland, writes liability coverage for almost half the doctors in Greensboro, about 300 of them, and in recent months Ward three times has been unable to find insurance for local physicians — at any price.

    "I had to tell those doctors to go home, shut their doors and tell the office they were sick," Ward said. "You have no insurance."

    ....There is no doubt of a problem. North Carolina providers saw an average premium increase on liability coverage of 50 percent last year, according to the U.S. Department of Health and Human Services. Only seven companies officially underwrite malpractice insurance in North Carolina right now — down from 10 just last year — and only four of them are truly active; no new players seem interested in entering the market, insurance observers say.

    One doctor sums up the situation succinctly:

    "If the insurance companies can't stay in business, then we can't get insurance. And if we can't get insurance, we can't practice," Amundson said. "If we can't practice, we can't provide health care. That's why this is a public issue."

    As usual, the trial lawyer association argues that caps for noneconomic damages only penalize the injured. (Funny, they never mention how caps also penalize trial lawyers.) This idea that an award of millions of dollars somehow compensates for injury deserves to be challenged.

    Whenever I hear that argument, I think of one of my patients who had a stroke during surgery. She sued and won a multi-million dollar award. It hasn't bought her happiness. It hasn't even bought her emotional adjustment. The stroke remains the defining moment of her life, and the source of a tremendous amount of bitterness and misery, which she inflicts not only on herself, but on all those around her. Sure, she lives in a beautiful new house now, complete with a lot of added features designed to make life easier for a person who can only use one hand. But, she doesn't use them. She prefers instead to require the assistance, and thus the attention, of her family members.

    I've had other stroke patients whose illnesses were not the result of surgery, but rather of random events, who are much worse off, but who function better both on a physical and emotional level. The difference is in their spirit.

    Putting caps on non-economic damages would not change any of this, of course. My patient would be equally bitter and dysfunctional no matter what the justice system did. And that's precisely my point - large monetary awards do not alleviate pain and suffering. They do, however, drive malpractice insurance companies - and doctors - out of business.

    UPDATE: A rebuttal from a trial lawyer. Just have to say, though, that from cases that I've read about in the news and heard about from colleagues, I have trouble believing that the cost of bringing a case makes the majority of trial lawyers overly selective in the cases they take. I've heard too many tales of frivolous suits being filed and then dropped only much later in the game. Also, can't say if I'm "conflating economic and non-economic damages" in this case. I don't know the details of the award. But, I suspect that a significant chunk of it was for non-economic damages.
    posted by Sydney on 4/06/2003 10:10:00 AM 0 comments

    Thoughtful Music: This concert gives new meaning to audience participation.
    posted by Sydney on 4/06/2003 09:36:00 AM 0 comments

    Gupta Update: CNN's Dr. Sanjay Gupta describes what it's like to operate in the field:

    It is hot, up to 110 degrees [Fahrenheit] here today and operating in non-air-conditioned operating rooms, sometimes in full garb and also a lot of dirt and sand. In addition to that -- the operating rooms are well-equipped, but for example today when we were doing this procedure for the gunshot wound to the head, we had to make do with the instruments that we had. So really, I was basically looking around the room saying, "OK, let's try these instruments over here. Let's try this particular material to try to create a closure over here."

    It's trying to make the best of what you can with scarce resources, and having said that, I will say it is truly remarkable in a way what they do have. This is a totally mobile operating room and the operating rooms are designed to be mobile so they can move with the troops and support the troops as soon as they come off the front line.

    So it's a little bit of both, but just every day, you look around and remember that you're in the desert. It's hot, there's lots of dirt and there are sandstorms and helicopters throwing up dirt coming in and out of here all of the time. If you think about that, it's really remarkable what they're able to accomplish, despite all of that.

    And, by the way, he operated again on a patient, this time with good results.
    posted by Sydney on 4/06/2003 09:36:00 AM 0 comments

    Journalistic Ethics: CNN’s doctor/medical correspondent, Sanjay Gupta, has sent media academics into a dither because he's been acting ethically, from a medical perspective. Gupta, who is a practicing neurosurgeon in addition to a reporter for CNN, is embedded with a group of frontline surgeons in Iraq, the Navy’s “Devil Docs”. They’re all general surgeons. He’s a neurosurgeon. When an Iraqi child was brought in with a schrapnel wound to the head, Gupta scrubbed in and performed neurosurgery. Unfortunately, the wound proved fatal, but the idea that a reporter would put his pen down long enough to try to help someone prompted the director of the ethics program at the Poynter Institute for Media Studies to tell the Boston Globe:

    ''I'm hoping and trusting that he and CNN set some thresholds,'' Steele said. ''I think it's problematic if this is a role that he's going to be playing on any kind of frequent basis. I don't think he should be reporting on it if he's also a participant. He can't bring appropriate journalistic independence and detachment to a story.''

    And the director of Columbia’s Project for Excellence in Journalism agrees, saying that now that Gupta has performed surgery, his “objectivity” is in question, especially since the Navy surgeons he works with praised his surgical skills. Yet, this same director had this to say about Peter Arnett's cozy relationship with the Iraqi government:

    "This is career suicide more than it is some great ethical breach," agreed Tom Rosenstiel, director of the Project for Excellence in Journalism, arguing that formerly strict rules against reporters commenting on stories they cover have softened in the face of media outlets' desire for publicity.

    So, it’s only a bad career move for a reporter to be so entrenched with a foreign government that he can’t objectively distance himself from their propaganda, but it’s a breach of journalistic ethics for a reporter to attempt to save a life. Is it any wonder that people trust the media even less than they trust politicians?

    UPDATE: There's a discussion of this in the comments section of the Blogcritics version of this post. If you're inclined to join in, please do.
    posted by Sydney on 4/06/2003 09:31:00 AM 0 comments

    Saturday, April 05, 2003

    Eye of the Beholder: In pursuit of ever elusive beauty.

    posted by Sydney on 4/05/2003 08:53:00 AM 0 comments

    Tales of Long Ago: A British physician sent in this account of a smallpox outbreak in Britain when he was a young doctor:

    Of the 18 contacts who developed smallpox, those who had ever been vaccinated survived after mild to moderate illnesses. One severely ill 84-year-old man who had been vaccinated once in infancy also survived. Using a vaccine fully active in others, I vaccinated the exposed unvaccinated nurses. But by then it was over a week since possible exposure, and these vaccinations did not take. Presumably during the smallpox incubation period, the more virulent variola virus had already induced enough interferon to prevent vaccinia infection.

    Previous vaccination protects well against severe or fatal illness, but cannot always prevent infection. Vaccination after exposure cannot be relied on, especially in the second half of the incubation period, when interference by the already established variola virus prevents the less virulent vaccinia virus from establishing itself.

    Interesting. One of the arguments that those against pre-attack smallpox vaccination make is that post-attack vaccination can prevent the already-exposed from developing the infection. Evidently, that isn't necessarily true.
    posted by Sydney on 4/05/2003 08:51:00 AM 0 comments

    The Spread of SARS: The Eyes Have It has collected two graphic representations of SARS and how it spread. The link to the Times graphic is the best - note the number of healthcare workers infected by just one patient.

    Elsewhere in the news, SARS has been added to the diseases worthy of quarantine, which means if need be, the government can force you stay in your house until you’re no longer sick. The list is nothing new. It’s been around for some time and includes such diseases as smallpox and cholera, but it’s the first time in a while that a new disease has been added to it.

    And, from the CDC press conference yesterday, we learn why the disease hasn’t been as fatal here:

    We are using a very broad, very nonspecific, but quite sensitive surveillance case definition here to pick up these 115 suspect cases.
    Now, having said that, though, why have we not seen one of these severely ill patients? I think we have been lucky, frankly. I mean, there is no better explanation at the moment, and we won't know until we get better information on risk factors, as they relate to exposure and individual susceptibility.

    Translation: luck.
    And there’s mounting evidence that the coronavirus is, indeed, the culprit - although it still isn’t certain:

    Evidence for this previously unrecognized Coronavirus has been found now in at least 10 laboratories, including the laboratories here at CDC. The preponderance of the evidence continues to mount and continues to favor an etiologic role or this previously unrecognized Coronavirus in the cause of SARS.

    So far, in looking at specimens from the suspect cases in the United States, we now have evidence of infection with this agent in a total of four people, and we are working with the state health departments in the states where these people reside, so that they are provided with the information and they, in turn, will provide the clinicians and the patients with the information.

    Now, let me give a little more detail on the extent of the laboratory evidence. We have cultured this Coronavirus from a total of four patients. We have electron microscopic evidence from two patients of this virus. We have PCR results--that is the Polymerase Chain Reaction, the amplification technique--where we find evidence of Coronaviral nucleic acid in 11 patients.

    Looking at the antibody tests, of which we have two--an IFA test and Allose test--there is evidence for infection in a total of five patients. And from the standpoint of histopathology, looking through the microscope at tissue from deceased patients, we have seen evidence of an entity that the pathologist call diffuse alveolar damage, which is the pathologic correlate for the clinical syndrome of Acute Respiratory Distress Syndrome, which has appeared in patients with severe forms of SARS.

    This last bit about the pathological changes in the lungs is a key difference between this infection and influenza. The influenza virus doesn’t, for the most part, directly attack the lungs. “Influenza-related deaths” are usually caused by complicating factors - the development of a pneumonia super-imposed on influenza, or hypoxia that makes a heart condition suddenly fatal. This virus, in contrast, seems to attack the lungs directly and damage them enough to cause a critical illness in a significant number of its victims.

    And, finally, is the CDC examining this outbreak for lessons in controlling and preventing a bioterrorist attack?

    This is a fire drill for a number of things. It is a fire drill for an unexpected, severe acute respiratory disease. The one of those that we know is going to occur one day is the next worldwide epidemic or pandemic of influenza. So those of you who have been interested in following influenza preparedness in the past ought to pay very close attention to this. This has many similarities to the way the next influenza pandemic might begin.

    Now, having said that, I am sorry, I have forgotten--well, let me,in terms of bioterrorism. Yes, I mean, we are operating through our Emergency Operations Center. That center was activated by Dr. Julie Gerberding, our director, back on March 14th, and it's been operating around the clock ever since.

    We're using that now. If we have a bioterrorism attack, we will be using that emergency operation center and doing many of the same things that we're doing now, operating through multidisciplinary, headquarters-based and field teams.

    So this a drill. We are building on our experience in dealing with anthrax, on the one hand, and also on our experience in dealing with West Nile encephalitis last summer as it swept across the country. And I would just remind everybody we're paying close attention to what's going on with West Nile Virus right now because, as things warm up, we're going to come back into West Nile transmission season before too long.

    Bioterrorism? What’s that to us when we have West Nile virus to worry about!
    posted by Sydney on 4/05/2003 08:47:00 AM 0 comments

    Now I've Seen Everything: For women who can't find a caring gynecologist - do-it-yourself pelvic exams and pap smears.
    posted by Sydney on 4/05/2003 08:11:00 AM 0 comments

    Applications: Jane Galt compares being pro-war/anti-war to false postive/false negative medical test results.
    posted by Sydney on 4/05/2003 08:10:00 AM 0 comments

    Not a JAMA Art History Lesson: I really miss posting the weekly art history lesson from JAMA. Why they decided to include it in the subscription-only part of their website is a little baffling, since their other entertainment items are free. But, since riding on their coattails is no longer an option, I’m going to try my hand at an art history lesson of my own. Call it Medpundit’s weekly art history lesson. (With apologies to Dr. Southgate)

    Charles Willson Peale (1741 - 1827) was the pre-eminent painter of early America and the founding father of a dynasty of American painters (four of his seventeen children, the aptly named Titian, Rubens, Raphaelle and Rembrandt Peale, became painters in their own right). He was also the embodiment of the quintessential American can-do spirit. Initially a saddler by trade, he decided to try his hand at painting after seeing some badly done portraits and thinking he could do better. He read what instructional manuals he could find, and then traded his finest saddle to a fellow Maryland resident and painter, John Hesselius for painting lessons. His reputation grew quickly, and soon a group of wealthy patrons sent him to England to study under Benjamin West. He returned to the North American colonies in 1769 and set up a portrait studio. It became his business to paint the prosperous in their best light.

<br />1772

    In 1772, he was commissioned to paint the portrait of a Virginia squire named George Washington. (Click here for larger image.) The retired colonel was forty years old at the time of the painting, and owner of a prosperous plantation. He stands before the craggy Virginia landscape wearing his old scarlet and blue British militia uniform, his gun in his hand and his sword at his hip. In his pocket is a letter with a visible signature. Although it is difficult to make out the signature, it was Peale’s habit to paint his lesser-known subjects with a letter or paper that bore their name for easy recognition. Standing there in that common 18th century pose, his right hand tucked in his shirt-front, the Virginia planter looks like a man quite satisfied and content with his lot in life.

    Washington at 
<br />Princeton

    Seven years later, Peale had occasion to paint Washington again, this time wearing the blue and gold of the American Army, and against the backdrop of the battlefield of Princeton. (larger image) The sword is still at his hip, but the gun has been replaced with a cannon. The Stars-and-Stripes waves proudly over his shoulder, while at his feet lies the British flag. No need for an identifying letter this time. Instead, there’s a column of captured British troops marching neatly into his right coat pocket. He stands looking directly at the painter, the complacency and satisfaction of seven years earlier replaced with an attitude of confidence and steely determination. The transformation from Virginia squire to conquering hero is complete.

    Charles Willson Peale went on to paint over a dozen more portraits of Washington, and many other patriots. Like many men of his time, he didn’t content himself with the pursuit of one interest. He also branched out into science, dabbled in inventing, and founded a museum in Philadelphia (which his descendants eventually sold to none other than P.T. Barnum.) Yet, it’s for his portraits that Charles Willson Peale is best remembered, and rightly so. For it is through his work that so much of our history remains alive.

    [ed. note - changed later to include the images in the site. Finally learned how to do that.]
    posted by Sydney on 4/05/2003 07:43:00 AM 0 comments

    Friday, April 04, 2003

    Wartime Medicine: [warning: self-promotion -ed.] We owe a lot to the armed forces, and not just because they protect our liberty. See my most recent Tech Central Station article about the impact of war on medical technology.

    posted by Sydney on 4/04/2003 09:35:00 AM 0 comments

    SARS Hysteria: Michael Fumento (who, by the way, has a very good article on biotechnology and bioterrorism) sends this note about SARS:

    One thing people just can't get into their heads, whether it's Ebola or SARS, is that nothing kick's an epidemic in the butt like good medical care. As it now stands, we've had 85 SARS cases here and no deaths. If you've ever been to China, and I have on three occasions, you'd know why they have all the SARS cases but about 300. Meanwhile, today the WSJournal ran TEN SARS pieces. Yeah, that's my definition of hysteria.

    Yes, that’s true about the quality of medical care having an impact. It impacts both the ability to take adequate care of the sick and to contain the epidemic with effective respiratory isolation measures. Here in the US, for example, we use disposable gowns and masks when entering an isolation room. I’m not sure that hospitals in every country can afford those sorts of measures. And, while there is hysteria - the school keeping students recently returned from a China trip at home, the State Department in China sending people home, etc., I still think the WHO is acting responsibly . Faced with an evolving, highly infectious disease, it’s wise to try to curtail it as much as possible. By one report, the disease results in a degree of respiratory distress severe enough to require critical care support in up to 20% of cases. That alone would put a tremendous strain on our hospital systems if the disease were allowed to go unchecked throughout the general population. And if the critical care services are taxed beyond their ability to respond, mortality goes up. In this case, an ounce of prevention really is worth a pound of cure.

    Meanwhile, the disease seems to be on the wane in Singapore, Australia's cases have dropped, and China has allowed the WHO to investigate their cases.

    And the CDC has an excellent SARS fact sheet up.
    posted by Sydney on 4/04/2003 09:09:00 AM 0 comments

    Pap Controversy: Here in the United States, the standard of care when screening for cervical cancer is to use a “monolayer” method. A sample of cells and mucous are obtained from the cervix (the opening of the uterus) with a spatula and a brush, and swirled around in a preservative solution to put the cells into a suspension. The bottle is then shipped off to the lab and a sample of the suspension is sprayed onto a slide in a thin, evenly distributed layer for the pathologist to review.

    This method is considered superior to the former method, the original Pap smear, in which the mucous and cells are smeared on a microscope slide, sprayed with preservative and shipped to the lab. The problem with this method being that sometimes the cells clump on top of one another or just get broken up in the process, making it difficult for the pathologist to properly assess their state of normality.

    Now comes a study from France that says the new method is inferior to the old, contrary to previously published studies. The French team compared pap smear results done by both the old and new method with biopsy results and close inspection of the cervix with a magnifying lense (called colposcopy). Both biopsy and colposcopy provide more definitive results than the screening pap smears. They found that the conventional pap smear was both better at sampling cells and better at predicting true abnormalities than the newer monolayer method.

    But, there is a major problem with the study. They were sloppy in the way they collected their specimens. Sloppy in a way that favors the conventional pap over the monolayer method:

    Each woman underwent a standard conventional smear test. The remaining material was then used to prepare the monolayer slide and for human papillomavirus testing.

    That means that far fewer cells were placed in suspension for the monolayer method than were placed on the slides for conventional evaluation. And, since pap smears rely on the quality and quantity of cells collected for their accuracy, it’s no surprise that the monolayer method faired worse. Fewer cells to examine equals less accuracy.

    And in fact, the greatest difference in the two methods was in the adequacy of specimens. Only 75 conventional paps were inadequate vs. 235 of the monolayer paps. This says it all. The authors claim that their method of sampling isn’t biased toward the conventional pap because they used a mathematical model to compare the two. But, math models are just that - models. You can’t argue with reality. And the reality is that the sampling method was biased toward conventional pap smears.

    A far better comparison would be between two groups of women - one of which had conventional paps, the other of which had monolayer paps. This would insure that neither method suffers from a diluted sampling of cells.
    posted by Sydney on 4/04/2003 09:02:00 AM 0 comments

    Bad Outcomes: Buried in this USA Today article on medical mistakes is the impact that patient deaths have on physicians:

    "One of the questions doctors ask themselves is, 'Did I kill this patient?' This is one of the most profound human experiences you can have, especially when you try to do good. For many of these people, it takes years to process this psychologically."

    Some leave their professions after such traumatic experiences. Charles says the physicians involved in errors often do not seek counseling. But many develop depression and sometimes post-traumatic stress disorder.

    In a report in the early 1990s, The Heart of Darkness: The Impact of Perceived Mistakes on Physicians, doctors described their emotions as angry, agonized, appalled, worried, guilty, fearful, embarrassed and humiliated. They have no place to turn, Barach says.

    It's hard to escape those feelings even whenever there's a bad outcome - even if no mistake has been made. Every decision has its consequence - and sometimes those consequences aren’t what we expected. An antibiotic could cause a fatal allergic reaction. What looks like gallstones from every aspect defies all expectations and turns out to be a heart attack. Or maybe the one question that would have yielded the one vital piece of information to provide the correct diagnosis didn’t get asked. Even when we do everything right, patients die. Yet, most of us, in those circumstances, still question ourselves. Wondering if we overlooked something that another doctor wouldn't have missed. It's tough trying to be perfect in an imperfect world. (Thanks again to Howard Feinberg)
    posted by Sydney on 4/04/2003 08:47:00 AM 0 comments

    Matter of Trust: Americans trust supermarkets more than hospitals, and just about everyone more than health insurance companies and managed care companies:

    While no industries were mentioned by majorities as being generally honest and trustworthy ("so that you would normally believe a statement by a company in that industry"), results varied widely among the different industries. At the top end, relatively large numbers trust supermarkets (40%), banks (35%), hospitals (34%), computer hardware companies (27%), packaged food companies (23%), and computer software companies (22%).

    On the other hand, only very few people believe that tobacco companies (3%), managed care companies (4%), oil companies (4%), and health insurance companies (7%) are generally honest and trustworthy.
    (thanks to Howard Fienberg for the tip.)
    posted by Sydney on 4/04/2003 08:41:00 AM 0 comments

    Lawyer with Heart: The Iraqi who was instrumental in rescuing Private Lynch was a lawyer who didn't like what he saw when he was visiting his wife, a nurse at the hospital:

    The friend walked him to the ground-floor ward, taken over by the feared Saddam Fedayeen at the start of the war, and past a window where he saw Lynch, an Army private first class captured after her convoy became lost near Nasiriyah in the opening days of the war.

    Her head was bandaged, her right arm was in a sling over a white blanket and she had what Mohammed thought was a gunshot wound to a leg. But her real problem then was the black-uniformed Fedayeen commander who everyone addressed as "colonel."

    The man slapped her, Mohammed said. "One, two," he added, making single slapping and back slap motions with his right hand. She was very brave, he recalled.

    "My heart cut," Mohammed added, meaning stopped, putting his hand over his chest and grimacing. "There, I have decided to go to Americans to give them important information about the woman prisoner."

    He walked through a combat zone to find the marines, then walked back to the hospital to make detailed maps of the place for them. He put both himself and his family at great risk to do so. (His neighbor had been shot for waving at a US helicopter.) In the end, the Fedayeen raided his house and took everything he owned. Now he and his family are refugees, at least until the end of the war. See, lawyers are capable of acting out of something other than self-interest. And how.

    posted by Sydney on 4/04/2003 07:52:00 AM 0 comments

    Thursday, April 03, 2003

    Miracle Vaccine: Is the flu shot a talisman against the grim reaper?

    Men and women over the age of 65 stand to gain a host of health benefits from getting a flu shot, including a decreased risk of dying of any cause during flu season, scientists reported Wednesday.

    ...To see if a flu shot might cut the risk, Nichol's team looked at more than 140,000 men and women 65 years and older during the 1998-1999 flu season and again during the 1999-2000 flu season.

    In 1999, 56 percent of the group had a flu shot; that proportion rose to nearly 60 percent in 2000.

    Vaccination against flu reduced the risk of being hospitalized for heart disease by 19 percent, according to the report in Thursday's issue of The New England Journal of Medicine.

    Additionally, those who got the flu shot reduced the chances of being hospitalized for cerebrovascular disease by 16 to 23 percent and the risk of being hospitalized for pneumonia or influenza by 29 to 32 percent.

    Overall, a flu shot cut the risk of dying of any cause by 48 to 50 percent, according to the report.

    That does, indeed sound like a wonder cure. The authors even use the phrase “protects against heart disease” in the original paper. But, the percentage of people - vaccinated and unvaccinated - who ended up dying or hospitalized for anything during the study was surprisingly small - 1.1% of vaccinated subjects were hospitalized for heart disease during the first study period compared to 1.6% of unvaccinated subjects. During the second period studied the figures were 1.2% vs. 1.4%. For death, the numbers were 1.2% for the vaccinated compared to 2.2% of the unvaccinated during the first study period, and 1.2% vs. 1.7% for the second study period. Hardly earth-shattering differences.

    Not that I don’t recommend the flu immunization. I do. The elderly are particularly vulnerable to influenza, and it helps cut down on complications from the disease. It definitely saves lives. It just doesn’t prevent heart disease and death from all causes.

    This sort of hyperbole only undermines the legitimate claims for vaccines. When you have researchers hyping the immunization as a preventive to heart disease in the media, it has the potential to cause substantial blow back when those expectations aren’t met. “What do you mean I had a heart attack? I had my flu shot this year!” Or, “Oh, no, my husband had one of those flu shots last year and he died anyways. I won’t have it.” We should be truthful about what our therapies can do. Taking the Madison Avenue approach to sell an immunization to the public is just wrong.

    posted by Sydney on 4/03/2003 08:04:00 AM 0 comments

    SARS Reassurance: Here's a graph from the New England Journal of Medicine that helps put SARS mortality in perspective. (Scroll down past the article links) Notice that while cases reported have climbed steeply to over 2000, the number of deaths have remained quite small in comparison.

    The same issue has the clinical details of the Canadian cases and a select few of the Hong Kong cases.

    UPDATE: And MSNBC's Weblog central has a nice collection of all the Southeast Asian blogs that are reporting on SARS. Really makes you appreciate the power of blogs and other internet technology to disseminate information.
    posted by Sydney on 4/03/2003 07:54:00 AM 0 comments

    Misleading Headline Award: West Nile was worse than thought implies that the West Nile virus was more contagious or made people sicker than we had been led to believe last summer, but that isn't the case. What the story is really about is that the people who had severe forms of it - specifically West Nile encephalitis - were left with residual neurological difficulties after their infections cleared:

    Fifty-four percent of patients admitted to three Chicago hospitals last year suffered from symptoms including vision loss, paralysis of more than half the body, muscle weakness, abnormally slow movement, numbness and an unstable walk, the study released Monday found--symptoms similar to those of Parkinson's disease, stroke, polio and other diseases that damage nerves.

    ..In the new study, researchers followed 28 patients from Rush, Loyola, University Medical Center and Cook County's Stroger Hospital.

    First of all, that's a very small number of patients from which to generalize about the disease. Secondly, encephalitis is, by definition, an inflammation of the brain, so neurological damage isn't unexpected.

    But, the researcher quoted in the article can't resist indulging in hyperbole:

    The findings indicate the virus might have mutated into a more dangerous form, Watson said.

    "It's more severe than in past epidemics," she said. "It's presenting with more virulent and more aggressive symptoms."

    The findings don't indicate any such thing, as Dr. Watson's partner points out:

    But Dr. Sidney Houff, a Loyola University neurologist who co-authored the study, said it's unlikely the virus has mutated.

    Clearly, Dr. Houff is the Holmes of the team. But, how else were they going to get the media to notice their paper amidst all the SARS news?
    posted by Sydney on 4/03/2003 07:52:00 AM 0 comments

    HMO Deathblow? The Supreme Court has dealt a blow to the HMO’s in knocking down their right to pick and choose among providers:

    Justices decided 9-0 that Kentucky can force health maintenance organizations (HMOs) to accept any qualified doctor who wants to join. About half the states have these so-called "any willing provider" (AWP) laws, and supporters say it gives patients greater choice and flexibility. The law was specifically designed to help low-income patients with limited health care options.

    Not surprisingly, the HMO’s don’t like it:

    HMOs and other groups call the policy "Bolshevik" health care coverage, arguing it increases patient costs because health care companies are prevented from choosing providers based on quality, price and volume.

    If HMOs "can no longer be selective, there will be cost and quality implications affecting the level of care" they can provide, said Robert Eccles, the attorney representing the health plans.

    The cased provided another example of the Court's continuing interest in federalism, testing the often conflicting balance of power between the national government and the states.

    Well, this will make it a lot harder for HMO’s to control costs. It just could be the beginning of the end for them.
    posted by Sydney on 4/03/2003 07:50:00 AM 0 comments

    Guitar Nipple Update: So, this is what "guitar nipple" is.
    posted by Sydney on 4/03/2003 07:47:00 AM 0 comments

    Cleve-Blog: Eric Olson is blogging for Cleveland.com.
    posted by Sydney on 4/03/2003 07:45:00 AM 0 comments

    Wednesday, April 02, 2003

    Contagion of Fear: We’re starting to get jittery. A Connecticut school has told students returning from a China trip to stay home for two weeks, for fear they could bring SARS to the school, and an entire airplane arriving in California from Asia was quarantined for two hours.

    And from Hong Kong comes this curious report:

    Fear of the spread of SARS caused Hong Kong officials recently to quarantine some 15,000 residents in a housing complex. Tuesday, some of those residents were being moved out so medical investigators could search for pockets of infection in the buildings.

    How do you detect pockets of virus in a building? Do they have those Star Trek scanners that magically tell you what's in the environment - from life forms to the chemical compostion of the air?

    posted by Sydney on 4/02/2003 05:26:00 AM 0 comments

    Joe Bob Does SARS: Joe Bob Briggs has about as good a description as any of the SARS virus:

    Fortunately, we have crack microbiologists in rubber gloves and surgical masks studying cultures on three continents, and so what we know is ... well ...

    In Hong Kong they say the disease is caused by the paramyxovirus family, which also causes measles.

    But wait! The Canadians say it's caused by the metapneumovirus family, which is rarely found in humans and, when it is, normally causes respiratory disease in children.

    But wait! The Americans say it's a coronavirus, similar to the one found in the common cold virus.

    But wait! The Canadians counter that it could be two viruses, not one, and that the coronavirus part of it is a mutant animal strain of coronavirus. Listen to this quote from Frank Plummer, scientific director at the National Microbiology Laboratory in Winnipeg, "It's somewhere between a mouse corona, a bird corona and a cow corona."

    Thank you for being specific, Frank. Isn't this the point in the 1950s sci-fi movie where the scientists huddle around the examining table and say, "But, Dr. Streubing, it's mutating! It's changing! By Jove, it's never been seen on Earth before!"

    And he points out why it might have spread so easily in that Hong Kong neighborhood:

    You know those neighborhoods in Hong Kong where everyone is so jammed together that Jackie Chan can run across the roofs of buildings and leap out one apartment window and land in the apartment across the street? It's one of THOSE neighborhoods. Some guy could sneeze four apartments away and you could get it.

    Leave it Joe Bob. Only a chop-socky movie connoisseur  would have picked up on that.
    posted by Sydney on 4/02/2003 05:21:00 AM 0 comments

    A Different View: The WHO has done an admirable job of tracking and containing the SARS epidemic. In just two and half weeks, they’ve identified the probable culprit, and they’ve kept the majority of the outbreak localized to southeast Asia. (The number of cases elsewhere is small and limited to recent Asian travelers and their contacts.) But the New York Times provides a different view from a former doctor and current columnist in Singapore:

    As SARS spreads across the globe (Belgium reported its first case yesterday), many have been pointing their fingers at China, which has suppressed information about the illness after it first appeared there in November. The real problem is not how secretive China has been, but how ineffective the World Health Organization has been in creating and enforcing a public health policy suited for a global outbreak like this one.

    Since its founding by the United Nations in 1948, the agency has overseen the monitoring and reporting of illnesses — but its rules are binding only on its members. Its membership now includes 192 countries but excludes some nations that are not members of the United Nations, like Taiwan, which has recorded five cases of SARS. Moreover, the only diseases that members are required to report are yellow fever, plague and cholera. And if a jurisdiction declines to report, there are no legal consequences.

    What should we do to nations who fail to report their diseases? Hit them with economic sanctions, or invade them? The UN won’t even sanction military action against fascist dictators and rogue states with weapons of mass destruction who fail to comply with their disarmament resolutions.

    The op-ed goes on in a similar vein, lamenting the inability of the WHO to enforce any sort of international health policy. It reads like a plea for more WHO power. But the author also unwittingly points out why it would not be wise to give the WHO unlimited authority:

    ...but the agency's definition of a public health emergency is so broad — whether an illness is serious, unexpected, likely to spread internationally, and restrict travel or trade internationally — that it could apply to almost anything, or nothing.

    They’re doing the best job they can with the SARS epidemic, and it seems to be working, although imperfectly. I’d much rather have a spirit of cooperation among sovereign states than a dictatorial global public health regime. The appropriate role of the WHO is advisory. Each nation should be responsible for inacting their own public health measures within the constraints of their laws.

    Give the WHO unlimited powers, and you never know what could happen. Once an infectious epidemic has died down and things are quiet again, there’s always the danger that they’d turn their attention to noninfectious diseases (as is their want) and declare an obesity emergency or heart disease emergency - and confiscate our french, er, freedom fries.
    posted by Sydney on 4/02/2003 05:17:00 AM 0 comments

    NRO on Smallpox Defense: Jonathon Friedman’s piece on bioterror preparedness makes so many good points, it’s hard to know where to begin:

    Strategy is the device through which we control our fate despite adverse circumstances and conditions of uncertainty.

    Mass vaccination may be an imperfect policy with some risks - what policy isn't? - but it is a highly effective one, as it minimizes uncertainty and protects the public from one of the enemy's most potent weapons.

    The conundrum of the mass-vaccination skeptics is how to deal with risk, a subject that many Americans obsess over. They want information on the likelihood of a smallpox attack, and whether there is a "specific threat." Perfect information is demanded in order to make a perfect decision. And there lies the fatal flaw in their thinking.

    So true. We live in an imperfect world in which the complete elimination of risk is impossible. Yet, so many of us expect a world without risk that an entire class of lawyers has been able to make a very good living off that expectation, and it’s contributing to our paralysis when it comes to our self-defense:

    ..... Incredibly, lawyers frighten the bureaucrats more than bio-terrorists, lawsuits being a clear and present danger. We are more afraid of attorneys with files than of terrorists with vials.
    posted by Sydney on 4/02/2003 05:10:00 AM 0 comments

    Accounting: The NHS is calling for a posh maternity hospital to account for its high rate of cesarean sections:

    An exclusive London maternity unit used by celebrities including Victoria Beckham and Claudia Schiffer has been asked to account for its high level of caesarian operations.

    The unit at the Portland Hospital for Women and Children performs nearly twice as many caesarian births as the English average, according to a report by the National Care Standards Commission.

    And what will they say if the hospital just tells them their patients are too privileged to push?
    posted by Sydney on 4/02/2003 05:09:00 AM 0 comments

    AIDS Entrepeneur: Bill Gates is investing $60 million in research to find an anti-HIV cream. It's hard to criticize such a noble gesture and cause, but you have to wonder if spending that money on clean needles for African healthcare providers might save more lives. Especially when you read statements like this:

    Helene Gayle, director of HIV, TB and Reproductive Health for the Gates Foundation, said women were at greater risk of HIV infection than men.

    Given the low availability of female condoms, it was important to find other way that women can protect themselves, she said.

    "The imperative to find something that women can use to protect themselves from HIV is clear and urgent.

    "The only technology we have is a male-controlled technology - a condom."

    Is that true? That women are at the greater risk of HIV infection? I still don’t see this as often in women as I do other sexually transmitted diseases - say gonorrhea or chlamydia. I couldn’t find any reliable statistics (i.e. not from activist groups) about the sex distribution, though. Anyone who does have that information, I’d appreciate it if you could pass it along.
    posted by Sydney on 4/02/2003 05:07:00 AM 0 comments

    Into the 21st Century: Medpundit now has an RSS feed. (Many thanks to Dr. Jacob for his technical advice) Now, can I become a part of Medical Weblogs?
    posted by Sydney on 4/02/2003 05:01:00 AM 0 comments

    Tuesday, April 01, 2003

    SARS Update: Interesting development in Hong Kong. The apartment complex that had a surge of new cases, involved one block of apartments, and most of the cases were apartments that were stacked on top of each other (they were upstairs neighbors):

    The Hong Kong Department of Health has today issued an unprecedented isolation order to prevent the further spread of Severe Acute Respiratory Syndrome (SADS). The isolation order requires residents of Block E of Amoy Garden to remain in their flats until midnight on 9 April.

    The decision to issue the isolation order was made following a continued steep rise in the number of SARS cases detected in the building over the past few days. Concern about a possible outbreak in Amoy Garden mounted on Saturday, when 22 of Hong Kong's 45 new SAR cases hospitalized that day were determined to be residents of the estate. On Sunday, 36 of the 60 new patients admitted to hospital with probable SARS were Amoy Garden residents.

    Hong Kong health authorities today informed the public that a cumulative total of 213 residents of Amoy Garden had been admitted to hospital with suspected SARS since reporting on the disease began. Hong Kong's outbreak began on 12 March when health officials first recognized a cluster of cases of atypical pneumonia in the Prince of Wales Hospital.

    Of the 213 Amoy residents affected in the outbreak, 107 patients resided in Block E. In addition, most of these 107 patients from Block E lived in flats that were vertically arranged.

    That suggests that this virus can be transmitted through air ducts, which in turn suggests that you don't need much of a viral load to be infected. For most viruses, like colds, you have to come into contact with respiratory droplets - either by someone sneezing or coughing on you, or from touching someone's contaminated hand or lips, etc. (That's why it drives me crazy to see someone lick a page before turning it.) But, highly contagious diseases (such as smallpox) can cause infection with a minimal of contact because they don't require a huge glob of viral particles to start the infection. Rather worrisome.

    posted by Sydney on 4/01/2003 08:25:00 AM 0 comments

    Virus Hunters: Excellent piece in the New York Times about the WHO's efforts at tracking down the Asian pneumonia virus.
    posted by Sydney on 4/01/2003 08:20:00 AM 0 comments

    Lessons of a Contagion:(self-promotion) There are lessons to be learned for bioterror preparedness in the SARS epidemic. My article at Tech Central Station has the details.(/self-promotion)
    posted by Sydney on 4/01/2003 08:19:00 AM 0 comments

    Overlawyered Watch: The high cost of malpractice insurance for nursing homes, the current state of the fast food lawsuits, the Baycol lawsuits, and asbestos litigation. All that and much more at Overlawyered.com.
    posted by Sydney on 4/01/2003 08:16:00 AM 0 comments

    Tupperware Mutants: Research suggests that plastic could cause gene mutations. In rodents. In cages where their plastic has been eaten away by strong solvent. They aren't really sure how that translates to people who eat out of plastic containers.
    posted by Sydney on 4/01/2003 08:15:00 AM 0 comments

    Good News/Bad News: Doctors are prescribing fewer antibiotics than we did ten years ago, in an effort to avoid antibiotic resistance. But, we're prescribing more broad spectrum antibiotics (drugs that cover a wider range of bacterial species):

    Researchers looked at data from the Centers for Disease Control and Prevention from outpatient clinics and found that the number of antibiotic prescriptions doctors wrote decreased roughly 17 percent from 1991 to 1999. However, prescriptions of broad-spectrum antibiotics roughly doubled - from 24 percent to 48 percent for adults and from 24 percent to 40 percent for children.

    Overusing broad-spectrum antibiotics is just as bad as overprescribing antibiotics in general when it comes to fostering bacterial resistance to antibiotics. Yet, just as there's pressure from patients to be treated, there's pressure to select certain drugs. I can't tell you how often I've been told that "amoxicillin isn't strong enough," or that "only Cipro works for me." Those are beliefs that are very difficult to overcome, and trying to defeat them usually causes the "negative placebo effect" to kick in - when the treatment doesn’t work because the patient believes it won’t.
    posted by Sydney on 4/01/2003 08:13:00 AM 0 comments

    Medicine By Email: Reservations about the privacy issue remain a problem for wide-spread use of email between doctors and patients. Some companies are marketing secure systems, but the price seems a little high:

    MedStar Health, which owns hospitals in the District and Maryland, is offering a secure e-mail option to doctors affiliated with the hospitals. The pilot project is free for the first year. After that, doctors may have to pay an annual fee or $2.50 per e-mail they send. Other hospital corporations are considering similar moves.

    $2.50 per email is pretty steep. Expect that cost to be passed on to the patient, and if people balk at paying it or if insurance companies won't reimburse it (which they won't,despite the few who are doing it in the article) then forget about email.

    And then there’s the concern that patients will email with an emergency and go unanswered for a while:

    "How can a patient be sure that I'm sitting by my computer when they are trying to reach me?" worries David Eisenman, an ear, nose and throat specialist with a group practice in Washington. That's especially a worry for pediatricians, who will often take prescription refill requests or appointments by e-mail but are often reluctant to communicate by e-mail [about other matters] lest a message about an emergency go unnoticed.

    "If a parent phones in, we can assess the situation right away," says Jeffrey Bernstein, head of a four-doctor practice in Silver Spring, "but it's not possible to continuously monitor a computer screen to make sure we're not missing an emergency."

    This may seem self-evident. Who in their right mind would email a doctor about an emergency and expect an answer right away? You’d be surprised. A colleague of mine had an asthma patient arrest waiting for her to call back on a weekend. She couldn’t reach her because the patient had given the answering service the wrong number. I’ve had other patients leave messages on the office answering machine that were clearly emergencies instead of waiting for the answering service to pick up. It’s much too likely to happen.

    And diagnosing and treating via email? Not wise. Fewer and fewer people seem to believe this these days (including doctors) but you really do need to examine a patient to make an accurate diagnosis. Email is even worse than phone calls for this because it doesn’t have any real interaction (voice clues, the opportunity to get quick answers to a question about a symptom). In fact, most doctors who use email take their time in answering it:

    But even if you tell your doctor you'd rather he e-mailed than phoned you, you may still find yourself waiting longer than you'd like for a reply. In a survey last year by Harris Interactive, doctors said they respond to patients e-mail questions within 18 hours of receipt. But patients said they received replies about 30 hours after their messages were sent.

    I’d say that puts email somewhere between the fax and the phone for response time.
    posted by Sydney on 4/01/2003 08:10:00 AM 0 comments

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